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Death and Sandwiches

I pondered the question during a noon conference as I replayed the morning’s events, biting into an Italian hoagie, half-listening to a lecture on disordered sodium balance.

It certainly wasn’t the first time I had done it. But somehow, this man’s death was different.

I met him my first day on service and knew he didn’t have long. There wasn’t an organ in his abdomen that wasn’t caked with cancer. When I entered his room that morning I felt like a specter, here to tell him his days were numbered, as I studied the photographs of happier times lining his windowsill.

There he was, younger than I, beer in hand, sitting under a tree outside his college dorm. Then again, kissing his wife on their wedding day. Then beaming at his son walking across the stage at graduation.

Suddenly, he vomited an angry green liquid into the basin next to his bed.

“I’ve had enough,” he told me.

It had been hard for his family to accept, but once they did, relatives and friends from across the country packed his room. I entered each morning and addressed a small congregation, reviewing the previous day’s events, small and large, and updating them on any changes we planned to make that day. He lay in bed — in various states of consciousness — as his loved ones laughed, cried and reminisced beside him.

And then, he was gone.

I listened to his hollow chest. I felt for a pulse and tested for basic reflexes, searching for any sign of life. Then I walked out of the room and, minutes later, rejoined my medical team to continue our rounds.

As we huddled around our computers in a nearby hallway, I heard his family members sobbing, even though their door was closed. I gripped my mouse a little tighter and scrolled down.

“Does G.I. want to scope her?” I asked a first-year resident, referring to our next patient, who had been oozing blood overnight.

Again I heard them, louder this time. I couldn’t concentrate. I thought: Should we break and regroup? For how long? Is 15 minutes enough to forget that our patient died and his family mourns? Is 20 enough to consider instead whether our next patient’s calcium levels are too low and need to be supplemented?

As doctors, we pound on an old woman’s chest, breaking ribs and expelling gastric contents, in hopes that her heart will beat again. We tell a young man’s family he won’t get the liver he needs to live. Then just hours later — disturbingly, curiously, miraculously — we have dinner with a co-worker. We answer emails. We fold laundry, play tennis, book train tickets. And the next day, we do it again.

But leaving work behind for the day isn’t the hard part. The hard part is leaving one patient’s story behind when you turn to the next.

For many of us who care for patients, this type of emotional turbulence leads to exhaustion and burnout. Increasingly, hospitals and clinics are investing in wellness programs that employ techniques like mindful meditation, narrative medicine and group discussions to help staff members process the emotional demands of caregiving and reflect on their shared experience. These programs have shown positive, sustained effects on provider well-being, with research suggesting they help doctors find meaning in their work, reduce symptoms of burnout, and promote patient-centered, humanistic care.

These initiatives, I think, help us confront the great tension of practicing medicine: If you feel too much, you will never get through the day. If you feel too little, you won’t be human by the end of it. But viewing them as the solution misses a fundamental point. This tension is not an unintended, unwanted, modifiable consequence of the job. It is the job.

Evidence suggests that doctors consciously and subconsciously suppress their empathic response to patient suffering — and that this isn’t always a bad thing. One study used M.R.I. imaging to understand how physicians respond to watching others experience painful stimuli. Researchers showed physicians videos of needles being inserted into patients and found that, compared to non-physicians, they had a relatively blunted response in brain regions associated with empathy, but a greater response in areas involved in executive control and other higher-level cognitive functions. Related research suggests it’s not that doctors first feel empathy for pain, and then suppress it. It’s that, over time, they no longer seem to feel empathy for pain in the first place.

This blunted emotional response may have an upside. A doctor’s job is partly empathic and partly analytical, but research suggests that these two modes of thinking are in almost direct opposition within the brain. Because of the way our minds work, in any given moment, a rush of compassion will likely inhibit a burst of insight, and vice versa. Dampening our emotional response, then, can help free our analytical minds to more effectively act, advise, cut, diagnose and treat — often under conditions of great uncertainty.

We hear often that it is the merging of thinking and caring that constitutes the science and art of medicine. But research and experience suggest it isn’t so much the merging of the two — it’s the toggling between. Being an effective doctor — like being a good friend, parent, spouse or colleague — depends on our ability to explore and enrich both sides of ourselves at different moments in our lives.

I sometimes sit alone in the eerie calm that descends on hospital wards late at night. My stomach growls, my eyelids droop. I stare blankly at the screen ahead, reaching for the half-eaten sandwich next to my keyboard, slowly reflecting on the day’s events. I consider how often medicine forces us to think when we want to cry. And how sometimes — like in that moment — I cry and don’t know why.

My pager pierces the fragile silence. Room 32 has chest pain — and I need to do something about it.

Dhruv Khullar, M.D., MPP, is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.